Description
Case Study on Institutionalization, Subjectivity and Structural Contradiction: The Disciplinary Power of TQM:- Subjectivity is a term used to refer to the condition of being a subject and the subject's perspective, experiences, feelings, beliefs, and desires.[1] The term is usually contrasted with objectivity,[1] which is used to describe humans as "seeing" the universe exactly for what it is from a standpoint free from human perception and its influences, human cultural interventions, past experience and expectation of the result.
Case Study on Institutionalization, Subjectivity and Structural Contradiction: The Disciplinary Power of TQM
Abstract The principal idea in the present paper is that the study of institutionalization can be developed if informed with Foucault's disciplinary power concept. Empirically the paper centers on the institutionalization of TQM, particularly at the County Council of Värmland (CCV), the public health care authority in the region of Värmland, Sweden. At CCV, focus is on two groups; the new management and the old administrators. The analysis displays that the dissimilar discourses and techniques advanced by the groups frame their worldview, which cause a lack of reflexivity amongst
managers/administrators. In the remainder it is argued that the paper contributes to the study of institutionalization in two ways. First, it deepens the understanding of contradictions between conflicting social structures and, second, it elaborates on the relationship between the construction of subjectivity and institutionalization.
Key words: Organization studies, Institutionalization, Disciplinary power, TQM, Subjectivity, Social structure.
Introduction Power is an explicit or implicit focal point in general institutional theory within sociology (e.g. Bourdieu, 1977; Douglas, 1986; Giddens, 1984). In neo-institutional organization theory, power was implicitly treated until DiMaggio (1988) and Zucker (1988) placed it on the theoretical agenda. Even though some further theoretical elaboration have been made (DiMaggio and Powell, 1991; Lawrence et al., 2001), neo-institutional empirical studies explicitly devoted to power are still scarce. Focus in the few previous studies (Bealing Jr. et al., 1996; Collier, 2001; Dirsmith et al., 1997; McKay, 2001) has been on the shift of power on the intra-organizational and field levels as an effect of institutionalization.
Another important topic within neo-institutional organization theory, which has been at the center of attention in the empirical program connected to it, is institutionalization - the process of creation, reproduction and stabilization, i.e. objectification, of institutions (Meyer and Rowan, 1977; Meyer et al., 1994; Tolbert and Zucker, 1996). Hasselbladh and Kallinikos (2000) have, however, criticized the prevalent conceptualization of institutionalization. In particular they argue that "?the theoretical formulations are often too idealistic and broad to direct empirical research" (Hasselbladh and Kallinikos, 2000:700). In order to develop the study of institutionalization they create a framework informed by the thoughts of Foucault.
Power is a central concept in Foucault's works (for example Foucault, 1977; 1981; 1986). As is evident from Fulop's (et al., 1999) overview of power in organization studies, Foucault's disciplinary power concept breaks distinctly with previous conceptualizations of power. Fulop (et al., 1999) makes a distinction between four dimensions of power. The first three dimensions, which are associated with the works of Dahl, Bacharach and Baratz and Lukes respectively, conceptualize power as someone having power over someone else - the dominant, through different means, such as non-decision making and control of socialization, has power over the dominated. The fourth dimension is Foucault's view of power. Foucault resists treating power as a commodity. He rather argues that power is involved in everything people do. Central is also the close connection between power and knowledge. Foucault focuses on the how of power (for example: how does power constitute
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subjectivity?) instead on how power holders control those lacking power or the shift of power from one power holder to another (Foucault, 1977; 1986).
The present paper is devoted to making the neo-institutional study of power explicit. It aims to elaborate the empirical analysis of institutionalization from the perspective of disciplinary power. Since previous empirical examinations have focused the shift of power as an effect of institutionalization they should be positioned within Fulop's (et al., 1999) first three dimensions. This paper should be positioned in the fourth dimension, the "Foucault dimension". The reason for taking this point of departure is that such an approach to power will inform the study of institutionalization instead of treating power as an effect of institutionalization. It will in particular make possible a more precise study of institutionalization pleaded for by Hasselbladh and Kallinikos (2000).
In the first section of the paper a theoretical framework is developed, focusing on how disciplinary power informs studies of institutionalization. Following Hasselbladh and Kallinikos (2000), the concept of institution is divided into three levels; the ideal level, the discursive and the technical level. In accordance with the power/knowledge concept it is asserted that, in particular, the discursive and technical levels introduce a distinctive way of seeing reality and as a result functions as framing techniques disciplining and controlling people. The theory section is followed by a presentation of the constructionist methodology and qualitative methods used in the paper.
The empirical focus in the paper is the institutionalization of TQM; particularly at the County Council of Värmland (CCV), the public hospital facility in the region of Värmland in Sweden. At CCV a reform program (CCV 2002) was introduced in the later part of the 1990s. Inspiration for CCV 2002 was found in the New Public Management (NPM; Hood, 1995) movement, which has been the loadstar in the reform of public sector organizations since the end of the 1980s (Ferlie et al., 1996). NPM emphasizes business values, such as functional rationality, cost-effectiveness and productivity and is in sharp opposition to the traditional democratic values of Swedish public administration, such as political democracy, public ethics and security of life and property (Lundquist, 1998). In the paper, a group of managers at CCV, referred to as the new management, is considered advocators of NPM. Especially they 2
favored the discourse of Total Quality Management (TQM), which is an important building block of NPM (Ferlie et al., 1996; Power, 1997). The ultimate aim of TQM is to re-define the organizational practice in a way that makes the customers' needs and demands become the point of reference for the development and the design of organizations (Deming, 1986; Hackman and Wageman, 1997; Juran, 1988). A group of senior administrators, the old administrators, resisted the deliberate attempt to institutionalize TQM, since they favored the traditional Swedish approach towards public administration.
The empirical case is presented in three passages, each followed by an analysis. The analysis displays that the dissimilar discourses and techniques advanced by the new management and the old administrators frame and discipline their worldview, which cause a lack of reflexivity amongst managers/administrators. In the discussion it is argued that the paper contributes to the study of institutionalization in two ways. First, it deepens the understanding of contradictions between conflicting social structures and, second, it elaborates on the relationship between the construction of subjectivity and institutionalization.
Theory: Institutionalization and disciplinary power
Ideals, discourse and techniques of control The neo-institutional empirical program has mainly focused on the isomorphism of highly taken for granted social structures, i.e. institutions, that give meaning to (organizational) life, such as the organization (Brunsson and Sahlin-Andersson, 2000; Meyer et al., 1994; Zucker, 1987), the rational actor (Brunsson, 1985/2000; Meyer and Rowan, 1977) and the market (Friedland and Alford, 1991; Granovetter, 1985) as well as how institutions/ideas are reproduced (DiMaggio, 1991; Galaskiewicz, 1991) and diffused through fields of organizations (Fligstein, 1991). These analysis have been done from the birds' eye point of view, which means that the discourses and techniques of control that the institutional rules consist of have not been focused - as argued in the introduction, the theoretical formulations have not been precise enough to direct empirical research. In order to deepen the study of institutionalization, the focus in the present paper is on the discursive and technical level of institutionalization. Following Hasselbladh and Kallinikos (2000) the concept of 3
institution is divided into three levels; the ideal level, the discursive and the technical level.
Institutions are conceived as consisting of basic ideals that are developed into distinctive ways of defining and acting upon reality (i.e. discourses), supported by elaborate system of measurement and documentation [i.e. techniques] for controlling action outcomes. (Hasselbladh and Kallinikos, 2000:704)
The distinction between ideals, discourse and techniques is derived from the "?degree of detail and precision by which they describe the social items and relations to which they refer" (Hasselbladh and Kallinikos, 2000:704). Ideals express themselves vaguely, discourses are more precise and techniques specify rather precisely how the social world should function or is functioning. As an example, the institution of organization, does, according to Brunsson and Sahlin-Andersson (2000), consist of three basic ideals (or values as they prefer to name them): hierarchy, identity and rationality. These ideals are, however, carried by several discourses, for instance TQM (but it can also be balance scorecard, business process reengineering or some other normative management program), which consists of several techniques, in the case of TQM, process orientation, measurement of customer perceived quality, etc (e.g. Furusten, 2000). Focusing on the discursive and the technical levels does, nevertheless, not imply that the ideals should be abandoned totally in the analysis, since local practice often are translated adaptations of ideals (Czarniawska and Joerges, 1996; Latour, 1987). But to put emphasis on the discursive and technical levels will sharpen the study of institutionalization - for example by specifying the contradictions between conflicting social structures - and direct the analysis to focus on knowledge and power, topics that are central in the works of Foucault (1977; 1981; 1986; Clegg, 1989).
Disciplinary power To Foucault power is not a state, nor do certain individuals have power, as is assumed in what Foucault entitles sovereign theories of power (Burrell, 1988; Clegg, 1989; Fulop et al., 1999), which have been the point of departure in neo-institutional empirical studies of power (Bealing Jr. et al., 1996; Collier, 2001; Dirsmith et al., 1997; McKay, 2001). Instead power is everywhere - it permeates the whole society.
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According to Foucault (1977; 1986), power controls the human body to a greater extent than the sovereign concept presupposes, why Foucault names it disciplinary power. Disciplinary power manifests itself through discourses and techniques of control, which make people behave and think in a distinctive manner - more distinct than the cultural rules, such as the organization and the rational actor, which neoinstitutionalists have focused on. A Foucauldian power analysis is thus not concerned with TQM as a deliberate management means to subordinate employees or the change of power relations as an effect of institutionalization of TQM. Rather the focus is on how TQM affects the thinking of collectives and individuals engaged with TQMwork. Disciplinary power poses the question: What effects does TQM have on the opinions, judgments and beliefs of people? TQM is for example likely to make managers value the opinion of the customer and the techniques developed to measure customer perceived quality most probably directs management attention to certain expressions of the organization that, according to the models, have a great impact on the quality evaluation made by the customer, such as the level of empathy, responsiveness and reliability/trustworthiness expressed by the front-line employees (e.g. Parasuraman et al., 1985).
The effect that TQM has on the thoughts of people can more fully be understood by the close relation Foucault presupposes between power and knowledge. According to Foucault (1981) the project of modernism has legitimated and formalized the production of (positivistic) truths. The truth like status of modern knowledge, and its legitimated character makes it affect the thinking of human beings. Knowledge is, however, never value-free. Instead it transmits certain values and is the most important carrier of power.
We should admit?that power produces knowledge?that power and knowledge directly imply one another; that there is no power relation without the correlative constitution of a field of knowledge, nor any knowledge that does not presuppose and constitute at the same time power relations. (Foucault 1977:27)
Rather than questioning the validity of modernistic truths or to focus on the intentional manipulative aspect of the production process of such truths, Foucault has concentrated on the effects "truths" have had on the constitution of human beings; in
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particular on the creation of subjectivity. Knights and Willmott (1989:554) have made explicit how Foucault defines subjectivity: "Rejecting the essentialist view of human nature, subjectivity is understood as a product of disciplinary mechanisms, techniques of surveillance and power/knowledge strategies". By the subjection caused by disciplinary discourse people are thus constituted as subjects (Foucault, 1977; 1981; 1986). TQM could accordingly cause a dramatic lack of reflexivity and openness since it introduces a way of seeing that directs attention to certain factors while excluding alternative ways of viewing the same reality. It could be suspected that TQM, as other "trendy" normative management discourses, has a definitive framing effect (Edenius and Hasselbladh, 2002); i.e. that it explicitly obstructs broadmindedness while it produces narrow-minded focus on the customers' needs.1 In addition, power/knowledge strategies of the past that have institutionalized the current practice of organizations, do, compared with TQM, constitute contradictory subjectivities and ways of seeing and acting upon reality. When TQM is introduced in a certain practice it can, furthermore, be expected that there will be disagreements between the advocators of TQM and those disciplined by the current practice. Such disagreements might, for example, cause de-coupling, that is TQM affecting the formal structure but not the actions of employees (Meyer and Rowan, 1977). By studying the conflicting ways of seeing reality the discourses and techniques of controls introduces it will be possible to explain the contradictions between social structures more fully, compared to a sole focus on the ideal level of institutionalization.
Summary When institutionalization is studied from a Foucauldian perspective the neoinstitutional birds eye point of view has to be abandoned. According to Foucault (1986) disciplinary power manifests itself through the discourses and techniques of every day life and not through ideals. When focusing on power from this perspective it is thus important to study how discourses and techniques affect the thinking of people in general and how people are created as subjects in particular - the "how" of power.
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Methodology The methodology approach of the paper can be called constructivist, which is found to be in line with Foucault's assumptions of social reality. With "constructivist" is here meant that TQM and other management discourses have a performative status; they serve "?to construct a particular field of visibility" (Miller and O'Leary, 1987:239). Rather than viewing TQM as a neutral tool for "seeing" reality it is acknowledged that TQM actively creates social reality. It can be argued that the performative character of a particular discourse and techniques of control associated with it are most visible in the actual process of organizing, why focusing on processes of institutionalization in a single organization is a advantage compared to a field focus.
The methods used to gather data of the TQM-work at CCV were interviews, participant observation and the study of documents. The empirical study lasted approximately two and a half years (from the fall of 1998 until the beginning of 2001). Altogether 60 hours of unstructured interviews were collected from CCV employees (mostly administrators, doctors, and nurses) as well as approximately two months' time of participant observation of meetings regarding CCV 2002 (extensive informal "chatting" not counted). In addition to this, everything written in the daily regional newspapers from 1990 to 2000 about CCV (approximately 25 folders of material) as well as internal documentation on organizational development that had taken place during the same time period was studied. The empirical material was structured with the help of Membership Categorization Analysis (MCA) technique (Silverman, 1993). Focus in this paper is on the administrators. The material was therefore initially ordered in several categories on the basis of the positions of the administrator and to what part of the organizations they belonged. The next step in the structuring process was to arrange these into main categories, a process called Membership Categorization Device (MCD). Silverman (1993) lists a number of rules on how MCD is to be constructed. The purpose with the rules is to help group the individuals so that those who are bonded through common views are placed in the same Membership Category. The MCD analysis resulted in the formation of two main categories - the new management and the old administrators - who struggled on what the official management discourse at CCV should be.
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Empirical case and analysis In this section the empirical case is presented in three passages. Each of them is followed by an analysis. Before the actual case is presented an account for the Swedish health care is made.
The Swedish health care, which principally is a public service, is divided into 28 geographic areas - County Councils (CCs) - that form detached administrative units. The governmental law of medical care provides a frame for each CC, but within this frame, freedom is quite extensive. Each CC has a political assembly and elections are held every four-year. The political body has the right to take up tax from the population of the county. Besides politicians, the CCs employ medical staff to do the actual health care and administrative staff to administer the decisions of the politicians. In Swedish doctrine of public administration it is an imperative that politicians should decide about what shall be done and the administrators ought to decide how these things should be done (Lundquist, 1988). During the 1990s' the Swedish health care suffered increasing budget deficit. This situation made the government implement a law in 1999 that stipulated that the finances of the CCs should be in balance by 2002 otherwise they could be subjected to administration by the state.
In response to this law several CCs implemented techniques for cutting costs. Most of them simply made budget cuts. The County Council of Värmland (CCV), however, implemented a TQM-program. The rational for this was that politicians and administrators thought that TQM should make people work more efficiently, which in turn could make CCV cut personal and then, off course, costs. The empirical case outlined in this paper concerns the TQM work at CCV between 1996 and 2001 as well as the prehistory of it from the beginning of the 1980s'. In the empirical presentation focus is on two groups of administrators; the new management (hired approximately at the same time as the TQM-program was introduced) and the old administrators (most of them had been working at CCV since the late 1970s).
Before the TQM-program The studied TQM-program (CCV 2002) was introduced at CCV in the middle of 1998 and was by most considered as an attempt to radically change the organization. The 8
reason for the latter was mainly that the formal organization at CCV had not been changed since the end of the 1970s. Back then a geographical based formal structure was introduced, dividing CCV into five administrative districts - the east, the west, the north, the south and the central district. Each of these districts had a hospital and was administratively run by a department director, medically by senior physicians. Each of the hospitals provided the population within their geographical area with basic care, which meant that they mostly served the older segment and children. The hospital in the central district was bigger and had more specialists and therefore provided more advanced health care to the whole population of Värmland as well as basic care to the population within the central district. There was also a central level at CCV with the office of the County Council Director (CCD) and among the staff there were the senior administrators. The CCD was not (formally) in charge over the five local departments, and most thought that this was an advantage, because decision concerning whole CCV was made in consensus in the managerial body of the CCD, where the department directors were members. The organization at CCV can thus be described as loosely coupled (Weick, 1979).
The management discourse at CCV was named the Värmland Way (VW) and was introduced by the same time as the new formal structure; in fact the structure was an effect of VWs central value; small-scaleness, even though it was put on paper later. With small-scaleness was meant that the five hospitals should remain. In internal documents three reasons for keeping the hospitals are presented. First, the five hospitals meet the need for closeness. The need for closeness was foremost a time issue in the emergency face, but also a social issue since relatives and friends easily could visit. Second, the kind of health care that was carried out at the hospitals was characterized by the need for different competences at the same time. The needed collaboration was thus enhanced in a smaller hospital, compared to a bigger one. Third, a smaller hospital was considered easier to manage than a bigger one (Internal documents).
Among the senior administrators at the central level the consensus concerning the management discourse was high - almost all of them thought that VW was the right way to organize the health care in Värmland. A major problem for them was, however, to handle the tension between the five administrative districts, which 9
became rife in times of budget negotiations. The final district budget was based on the annual budget estimates proposals made by the districts. In the beginning of the 1990s quite many thought that the budget process was unfair, since it favored those with good rhetoric skills rather than those with actual needs. The districts explicitly criticized the senior administrators at the central level, and implicitly VW, for not having developed a fair budget process. The debate in the regional media was at time intense and heated. As VW was dependent on the support from the districts a new budget technique, called population based budgeting, was developed in order to establish a more fair distribution of the economic means. This type of budgeting "?meant that we distributed money on the basis of the age structure of the population that the departments served" (senior administrator). The basis for that distribution was found in national statistics, which displayed that the cost of health care varied depending on age group. According to the administrators the new system made conflicts decrease, which most probably was the case since the debate in the media (concerning the issue of budgeting) decreased and after some time ceased.
Analysis The pre-history of the TQM work reveals VW as a distinctive and highly taken for granted, i.e. institutionalized, administrative discourse by senior administrators. VW seems to be a translation of the general Swedish ideal of public administration, which emphasizes democratic values, such as political democracy, public ethics and security of life and property (Lundquist, 1998). The central value of VW, small scaleness, manifests that. It hence seems that the administrative discourse at CCV is embedded in the institutional environment of the Swedish public sector. VW is a bit fuzzy at the technical level, but lately population based budget has been created to protect VW from criticism from the departments. Population based budgeting is a technique in line with the democratic values, manifested in VW, at CCV.
Interesting to note is that VW is unaffected by the new public management (NPM; Hood, 1995) ideal that begun to be popular within the Swedish field of health care at the end of the 1980s (Klausen and Ståhlberg ed., 1998). Rather, explicit arguments are formulated against that ideal in internal documents. The administrators seem to think that there is a fundamental opposition between NPM and the institutionalized approach to public administration. Another interesting aspect of the administrative 10
practice at CCV is that the administrators prefer to develop their own techniques instead of importing ready-made ones from the field. This is the case of population based budgeting. The administrators thus like to be independent in their creation of management techniques. This independence, however, is only a quasi independence, since they are disciplined by VW, which in turn is a translation of the ideal of public administration.
To conclude; VW is the taken for granted administrative discourse at CCV. The discourse is thus the legitimated systems of knowledge for administer health care. In accordance with Foucault (1977) VW disciplines and frames the actions and thoughts of the senior administrators. They are unwilling to embrace more recent ideas on how to manage public organizations.
The evaluation phase The first of December 1996 a new County Council Director (CCD) with great experience from administration in the field of social politics, but, however, not from managing health care, was hired. Almost everyone, politicians as well as administrators and physicians, thought that she was a successful recruitment. Within days after her arrival the politicians ordered her to do an inquiry. The inquiry was to center on how CCV could become a learning organization " ?where quality development from a customer perspective is the most central issue" (internal document). In addition to the inquiry an analysis of the environment was to be made. Two consultants got the latter mission and conducted a SWOT-analysis on the basis of interviews with prominent persons from public and private organizations within the region of Värmland. The two consultants reported no strengths, but quite many weaknesses. Amongst the later was that the administration suffered from lack of innovative power and CCV was characterized as a bureaucratic organization with a heavy "superstructure". Moreover, the systems of management were underdeveloped: "?CCV has an indistinct organization- and management structure, holistic approaches are lacking as well as overall strategies" (consultant report). The most important weakness in the health care was that the prevailing geographic organization caused ineffectiveness. "The care provided at each hospital has to be reviewed as well as the local management structure" (consultant report). The consultants thus implied that the formal structure would facilitate from being changed. According to the two 11
consultants the opportunity for CCV was to create a clear and consistent management culture, based on policies (which the consultants found missing in important areas) and a management philosophy.
A team that consisted of administrators, physicians and nurses, and was led by the new CCD handled the issue of learning organization and quality development. The general theme of the report that the team produced is that in order to form a learning organization and enhance quality development the processes should be developed guided by the customers needs and demands, the latter is a central thought in the TQM literature. Interestingly to note is also, that in the team conflicts arose between the CCD and two administrators, where the latter argued that they worked to fast and that no time for reflection was given which the administrators considered was not in line with thoughts of learning organization.
In 1997 the CCD also tried to strengthen the mandate of the central managerial body, which by most administrators was interpreted as a way for the CCD to increase her power and was therefore criticized. When the report of the consultants became public the conflict spread amongst the administrators of the organization, which was recognized by the CCD. "After two weeks the resistance was over me" (CCD). The conflict between the CCD and the administrators further increased when the former announced that the senior administrators' job-contracts were ended and that they would have to apply for their positions in competition with external candidates. The effect of this, besides that the conflict increased, was that three new senior administrators were hired amongst them the finance director who, together with the CCD, became the driving force of the TQM work within CCV.
Analysis Two interesting themes are to be noted from the empirical description in this subsection. One, that a new management discourse is imported to CCV, and two, that this new discourse is not very popular amongst the old administrators; the latter have been noticed in previous critical studies on TQM (Kelemen, 2000). It is a bit early to analyze the new management discourse in-depth, but it is certainly inspired by TQM and emphasizes values of formal control and effectiveness. This stands somewhat in opposition to the institutionalized administrative discourse, VW, which emphasized 12
democratic values and, as argued above, could be seen as an expression of the Swedish ideal of public administration (Lundquist, 1988). This ideal has lately, however, been challenged by the ideal of NPM (Hood, 1995), which emphasizes business values, such as functional rationality, cost-effectiveness and productivity (Lundquist, 1998; Power, 1997). The later ideal manifests itself through management discourses such as TQM (Furusten, 2000). One reason for the old administrators to resist the reforms announced by the CCD is thus that the new discourses stand in opposition to the institutionalized administrative discourse at CCV - in the frame of VW, TQM does not make sense to the old administrators.
The TQM program In spite of the conflict that arose between the CCD and the administrators at CCV the politicians decided to implement TQM. They probably thought that the conflict should ease since new senior administrators had been hired. The decision to implement TQM was taken in May 1998. Soon afterwards a task force was formed in order to start the process of implementation. This task force consisted of administrators, both new and old, senior physicians and some nurses. On the first and second meeting, a week in June and two days in August 1998, a business plan was written, that set out the basic thinking behind the TQM-work. Three goals were formulated: satisfied customers, satisfied employees, and balanced finances. The goal of satisfied customers and employees was to be measured each year. The measurements were to be linked to departments at CCV. If a department did not improve, some change at the department had to be carried out, for example a change in management.
It will take some time to establish the needed systems, but when we have them, when they are working; we will have a system that enables to put pressure on the middle managers [e.g. senior physicians and administrators] to fulfill their goals. If they don't do that we will simply replace them (finance director).
The actual TQM-work was to be carried out by process groups, which consisted of organizational members specializing in the area that the process group was responsible to develop, for example emergency care. The process groups should thus
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be responsible for adapting the overriding goal of the business plan into concrete goals for the specific discipline, and to implement this adapted version of TQM.
The next meeting of the task force centered on the work of the process groups. The basic idea was that the process groups should do their work during one internship week. When the members of the task force discussed the internship week, the senior physicians and the old administrators objected, because they could not let their personal be on leave for a whole week. The new finance director responded to that saying it is important for the process groups to be on a weeks meeting, arguing that their values and norms had to be changed if the TQM-program was going to be successfully implemented. The senior physicians, supported by the old administrators, said that they did not think that one week would change values and norms of their personal. The finance director and the CCD responded that the new way of working probably was unfamiliar to most of the members of the task force but they were quite sure that the TQM-work would change the values and norms of organizational members.
The conflict between the old administrators and the new management didn't ease until the CCD and the finance director, in late 1999, were forced to leave their positions, which also was the deathblow for CCV 2002. From interviews conducted with the new management and the old administrators during 2000 it is evident that they give different reasons to the emergence of the conflict. The new management thought that CCV was a very old fashioned organization that was unaffected by the NPM-reform program which they argued had affected most parts of the Swedish public sector.
After working 25 years in public organizations, CCV was a completely new experience. You haven't seen such a backward organization as CCV. (finance director).
In other words, the new management argued that CCVs history made the organization hard to change and that the old administrators didn't now how a modern organization should be managed. A second obstacle to change was, according to the new management, the administrative discourse VW.
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The overall policy driven by them [the old administrators] was that all five hospitals in Värmland should be preserved. This was stated in the Värmland Way, which was their baby, their creation. CCV 2002 had no such stipulated rule. Therefore they appeared as the knights and defenders of the five hospitals, which many thought was good to have. (CCD)
The new management criticized the prevalent practice for being inflexible and urged for a change, driven by the TQM program. The old administrators, which were proud of the organization that they had developed over the years, felt wrongly criticized, which according to them was one reason for the conflict.
Very much of the spirit here was; get rid of the past, weed out. This spirit became more evident when the finance director was hired; the spirit of rejecting history and put emphasis on the changes ?but things were not as bad as they [the new management] described it. If they had been a little keener to put emphasis on the positive side of our history, they could have been very sharp on the critique as well. The critique they put forward was to sweeping. If they had specified their critique, they might have established trust and mutual confidence. (Administrator)
The old administrators also thought of the new management as hypocrites, since the former argued that the latter's word and deed differed significantly. The new management said that organizational members should be given opportunity to involve himself or herself in the TQM-project, but according to the old administrators it was a widely-held opinion throughout the organization that only a few felt involved. The new managements ambition to formalize the loosely coupled organization was neither very popular amongst the old administrators.
We had an informal way of working here. We thought that this was an advantage. I once described it as we had a very informal structure with very well used paths. We walked those paths and had some shortcuts as well. But the new County Council Director never understood the advantage with those paths. In fact I don't think she ever saw them. She couldn't push herself throw all the virgin forest, maybe because she was more into the latest organization theory. I understood quite early that she did like to put all the theory that she had read into practice. (Administrator)
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To conclude, the new management thought that the old administrators were responsible for the creation of an old fashioned organization, which was hard to change. The discourse of VW obstructed change. The old administrators felt wrongly criticized, because they did not think that the prevailing practice was as bad as the new management said it to be. The old administrators thought that the new management couldn't see the bright sides of the practice of CCV because they were to occupied with all the "organization theory" they had read.
Analysis This section clearly reveals that there is an open resistance concerning TQM from the old administrators' point of view, and that they find support from the physicians. The major resistance is somewhat surprising since the old administrators as well as the physicians were involved in writing the overall business plan, which outlines the TQM ideas. It could, however, be argued that the details of the project and its implications become evident for the first time on the observed task force meeting. The physicians did not expect the introduction of the internship week, that the rational of this week was to change values and norms, that customer and employee attitudes should be measured etc. At first the old administrators and the physicians were seduced by the language of TQM - who can say no to the beautiful language of customer orientation, satisfied employees and finances in balance? But when TQM was translated into practice it became obvious that sacrifices would have to be done in other areas not initially spelled out by the TQM-advocators. When the techniques of TQM are introduced, when TQM should start to produce the effects it promises it becomes evident what sacrifices TQM demands. By acting in accordance with TQM, administrators and physicians push away the prevalent practice, which is the prime reason for the resistance of the TQM-initiatives.
But it also becomes evident that the old administrators were disciplined by the discourse of VW to the degree that they could not take in ideas that deviated from "the right way". They were unable to see the benefits of TQM and stuck to the old management discourse in spite of the acute financial situation it had created. The new management on their hand are prisoners of the TQM discourse. The management courses they have attended and the "organization theory" they have read and their experiences from other organizations all points to the fact that the practice of CCV 16
has to be changed radically. The ideas of customer orientation, productivity and efficiency are to them prerogatives and they are surprisingly much lacking the ability to value a more traditional approach to administer public organizations and the techniques connected to it. The "truths" that both groups believe in seem to determine their subjectivity to a great extent.
There thus seems to be a dramatic lack of reflexivity at CCV. The old administrators and the new management are almost completely disciplined by VW and TQM. The techniques associated with TQM and VW function as framing techniques; directing attention to certain areas of reality and introduces artificial management holism (Edenius and Hasselbladh, 2002). TQM seem to have the most distinctive framing effect due to the specifying character of TQM techniques. The interviews support this reasoning, since the new management TQM based argumentation is underlined by a performative rationale (Miller and O'Leary, 1987); the disciplinary effect of TQM makes them try to recreate reality. The new management completely lacked the eyes to see the problems that TQM caused at CCV.
Discussion and further research It is safe to say that a power analysis informed by the writings of Foucault focuses the construction of worldviews and subjectivity instead of the shift in power, which has been the focus in much previous empirical studies (Bealing Jr. et al., 1996; Collier, 2001; Dirsmith et al., 1997; McKay, 2001) of power within neo-institutionalism. In this section I will argue that the present paper has added to the study of institutionalization in two ways. First; it has elaborated on the increasing level of contradiction between conflicting social structures when they are translated from ideals to techniques via discourse. Second; it has implications for the relationship between construction of subjectivity and institutionalization.
Structural contradiction In the introduction of the paper it was argued that the neo-institutional theoretical formulations are not precise enough to direct empirical research. A distinction between ideal, discourses and techniques was made in order to connect neoinstitutional theory with the concept of disciplinary power, which was expected to
17
precise the analysis. I believe that the Focualdian inspired analysis has served that point, which I tend to show by discussing the concept of de-coupling.
The effect of the studied TQM-program in terms of neo-institutional theory is quite clear. TQM ideas institutionalized the formal structure but became de-coupled to the taken for granted action and thought schemes of organizational members, since the core of the new management were forced to leave their positions. Following Meyer and Rowan (1977) the reason for de-coupling should be found in that there is a conflict between the technical core and the form undergoing institutionalization or between two or more social structures. In the case outlined in this paper we have seen a conflict between the new management and the old administrators, which restrained the process of institutionalization and led to de-coupling. According to Meyer and Rowans (1977) formulation of de-coupling this would be explained through the conflict between the traditional ideal of Swedish public administration, preferred bythe old administrators, and NPM, favored by the new management. On the ideal level, however, the contradiction between social structures is not total. Or to put it differently; the traditional Swedish ideal of public administration has room for some functional rationality and NPM has room for political democracy. Ideals do not control the action and thoughts of people precisely, which is assumed by the neoinstitutional field level research where the ideal level usually is the sole focus. The institution of organization (Brunsson and Sahlin-Andersson, 2000), referred to in the theory section, consists, as an example, of ideals (hierarchy, identity and rationality) that do not distinctly specify people's taken for granted action and thought schemes when institutionalized.
When the ideals are translated into discourses the level of contradiction increases. Organizational members disciplined by TQM discourse will hardly acknowledge the small-scaleness of VW; from the standpoint of TQM there is no such absolute values - the customer has to decide. The other way around, for advocators of VW, or similar translations of the Swedish ideal of public administration into local management discourse, it will be hard to accept the kind of customer-based evaluation of the organization that TQM introduces. When techniques are introduced in the analysis there is an even higher level of contradiction, which the techniques translated from NPM clearly demonstrate. Measurement of customer perceived quality directs senior 18
managers to replace middle managers that don't keep the scores high enough, which is in sharp opposition to the practice derived from VW. The techniques of TQM thus have an obvious preformative touch; people are defined and truly controlled by them. De-coupling is hence not solely explained by the conflict between ideals. The increasing and at the end almost total contradiction between discourse and techniques give explanations of de-coupling more precision.
There is, however, no per se contradiction on the discursive and technical level between two or more conflicting ideals, such as the doctrine of public administration and NPM. The ideal level leaves enough "translational space" for the adaptation of new discourses and techniques (or the standard versions of them applied) to the taken for granted discourses and techniques defining practice. It would be interesting to study institutionalization where discourses and techniques adapt to each other instead of the opposite. Such a study could contribute to the understanding of organizational and institutional change (Greenwood and Hinings, 1996) as well as to how colonization (Power, 1997) of organizations comes about.
Subjectivity In the introduction it was also stated that power in previous neo-institutional empirical analysis has been treated as an effect of institutionalization. In particular the students of institutionalization have shown how shifts in power take place when new forms are institutionalized in a field or in an organization (Bealing Jr. et al., 1996; Collier, 2001; Dirsmith et al., 1997; McKay, 2001). These studies have been based on the assumption that certain people or groups have power over others; an assumption that Foucault rejects (Foucault, 1977; 1986). From a Foucauldian perspective it will rather be claimed, as I intend to make explicit that this paper does, that power precedes and has a significant effect on institutionalization.
In the present paper it has been stressed that discursive practices of power/knowledge discipline people's thinking. In accordance with Foucault (1977, 1981) it could further be asserted that the disciplinarian effect of discourse has great impact on the constitution of subjects, especially in situations of organizational change. In the particular case analyzed here the Swedish ideal of public administration, the discourse of VW and the technique of population based budgeting produce the "bureaucratic" 19
subjectivity of the old administrators and that the ideal of NPM, the discourse of TQM and the techniques associated with TQM produce the "business" subjectivity of the new management. Subjectivity defines people's field of visibility. It can consequently be claimed that even if TQM does not institutionalize the practice of an organization it creates a field of visibility for the advocators of it. The same rationale probably follows from other power/knowledge practices that are popular today, such as Business Process Reengineering (BPR) and Balance Score Card (BSC). If the subjectivities produced differ, certainly the case at CCV, different interpretations of organizational change are made that affect the process of institutionalization. Taking a Foucauldian perspective, power shall, hence, not be treated as an effect of institutionalization. Rather, as an effect of disciplinary power manifest in discursive practices subjects are formed, which have great impact on institutionalization. If the focus in neo-institutional studies of power is on what power does to people rather than the change of power, power will be an explanation instead of a result, a cause instead of an effect.
The specific reform situation thus produces certain subjectivities with great impact on the process of institutionalization that neo-institutional theory has a problem to account for. In order to more fully understand what effect subjectivity has on institutionalization a cognitive micro theory is needed (Zucker, 1977/1991), such as the sensemaking perspective (Weick, 1979; 1995), which is "compatible" with a Foucauldian subjectivity concept. Such a design should be able to explain and make explicit how subjectivity is produced when organizations encounter change initiatives as well as how these subjectivities effect the very process of institutionalization. It would thus be interesting to study the micro processes of institutionalization with Weick's sensemaking theory in order to explain how subjects are constituted and the effect that such a process has on institutionalization.
Conclusion The present paper has offered a description of institutionalization as well as an analysis informed by Foucault's disciplinary power framework. The center of attention has been on how discourses and techniques discipline people's construction of reality and their thinking in general. It was argued that the approach taken had implications for the study of institutionalization, particularly on the contradiction 20
between conflicting social structures and the effect construction of subjectivity has on institutionalization. It was believed that the two mentioned areas were in need of further investigation in coming neo-institutional research. Studying
institutionalization from the perspective of disciplinary power thus offers interesting ways of conceptualizing and thinking of institutionalization.
Notes
1
But according to Foucault (1977; see also Smart, 2002) TQM will most probably also have a productive effect; the focus on the customer might introduce a perspective that previously have been lacking in the organization, which might produce greater turnover or a more positive evaluation of the organization. Foucault (1973) have, for example, demonstrated how clinical observations established a new epistemological foundation in medicine, changing medicine from being a theoretical, scholastic occupation to establishing modern clinical medicine as the taken for granted discourse/knowledge. Clinical medicine have of course meant that diseases and illnesses is cured more efficiently than before, but it has also "framed" the thoughts and actions of physicians towards patients by introducing a certain subjectivity - effective alternative medicine are not used since they have not been tested following the techniques of clinical medicine.
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doc_570517401.docx
Case Study on Institutionalization, Subjectivity and Structural Contradiction: The Disciplinary Power of TQM:- Subjectivity is a term used to refer to the condition of being a subject and the subject's perspective, experiences, feelings, beliefs, and desires.[1] The term is usually contrasted with objectivity,[1] which is used to describe humans as "seeing" the universe exactly for what it is from a standpoint free from human perception and its influences, human cultural interventions, past experience and expectation of the result.
Case Study on Institutionalization, Subjectivity and Structural Contradiction: The Disciplinary Power of TQM
Abstract The principal idea in the present paper is that the study of institutionalization can be developed if informed with Foucault's disciplinary power concept. Empirically the paper centers on the institutionalization of TQM, particularly at the County Council of Värmland (CCV), the public health care authority in the region of Värmland, Sweden. At CCV, focus is on two groups; the new management and the old administrators. The analysis displays that the dissimilar discourses and techniques advanced by the groups frame their worldview, which cause a lack of reflexivity amongst
managers/administrators. In the remainder it is argued that the paper contributes to the study of institutionalization in two ways. First, it deepens the understanding of contradictions between conflicting social structures and, second, it elaborates on the relationship between the construction of subjectivity and institutionalization.
Key words: Organization studies, Institutionalization, Disciplinary power, TQM, Subjectivity, Social structure.
Introduction Power is an explicit or implicit focal point in general institutional theory within sociology (e.g. Bourdieu, 1977; Douglas, 1986; Giddens, 1984). In neo-institutional organization theory, power was implicitly treated until DiMaggio (1988) and Zucker (1988) placed it on the theoretical agenda. Even though some further theoretical elaboration have been made (DiMaggio and Powell, 1991; Lawrence et al., 2001), neo-institutional empirical studies explicitly devoted to power are still scarce. Focus in the few previous studies (Bealing Jr. et al., 1996; Collier, 2001; Dirsmith et al., 1997; McKay, 2001) has been on the shift of power on the intra-organizational and field levels as an effect of institutionalization.
Another important topic within neo-institutional organization theory, which has been at the center of attention in the empirical program connected to it, is institutionalization - the process of creation, reproduction and stabilization, i.e. objectification, of institutions (Meyer and Rowan, 1977; Meyer et al., 1994; Tolbert and Zucker, 1996). Hasselbladh and Kallinikos (2000) have, however, criticized the prevalent conceptualization of institutionalization. In particular they argue that "?the theoretical formulations are often too idealistic and broad to direct empirical research" (Hasselbladh and Kallinikos, 2000:700). In order to develop the study of institutionalization they create a framework informed by the thoughts of Foucault.
Power is a central concept in Foucault's works (for example Foucault, 1977; 1981; 1986). As is evident from Fulop's (et al., 1999) overview of power in organization studies, Foucault's disciplinary power concept breaks distinctly with previous conceptualizations of power. Fulop (et al., 1999) makes a distinction between four dimensions of power. The first three dimensions, which are associated with the works of Dahl, Bacharach and Baratz and Lukes respectively, conceptualize power as someone having power over someone else - the dominant, through different means, such as non-decision making and control of socialization, has power over the dominated. The fourth dimension is Foucault's view of power. Foucault resists treating power as a commodity. He rather argues that power is involved in everything people do. Central is also the close connection between power and knowledge. Foucault focuses on the how of power (for example: how does power constitute
1
subjectivity?) instead on how power holders control those lacking power or the shift of power from one power holder to another (Foucault, 1977; 1986).
The present paper is devoted to making the neo-institutional study of power explicit. It aims to elaborate the empirical analysis of institutionalization from the perspective of disciplinary power. Since previous empirical examinations have focused the shift of power as an effect of institutionalization they should be positioned within Fulop's (et al., 1999) first three dimensions. This paper should be positioned in the fourth dimension, the "Foucault dimension". The reason for taking this point of departure is that such an approach to power will inform the study of institutionalization instead of treating power as an effect of institutionalization. It will in particular make possible a more precise study of institutionalization pleaded for by Hasselbladh and Kallinikos (2000).
In the first section of the paper a theoretical framework is developed, focusing on how disciplinary power informs studies of institutionalization. Following Hasselbladh and Kallinikos (2000), the concept of institution is divided into three levels; the ideal level, the discursive and the technical level. In accordance with the power/knowledge concept it is asserted that, in particular, the discursive and technical levels introduce a distinctive way of seeing reality and as a result functions as framing techniques disciplining and controlling people. The theory section is followed by a presentation of the constructionist methodology and qualitative methods used in the paper.
The empirical focus in the paper is the institutionalization of TQM; particularly at the County Council of Värmland (CCV), the public hospital facility in the region of Värmland in Sweden. At CCV a reform program (CCV 2002) was introduced in the later part of the 1990s. Inspiration for CCV 2002 was found in the New Public Management (NPM; Hood, 1995) movement, which has been the loadstar in the reform of public sector organizations since the end of the 1980s (Ferlie et al., 1996). NPM emphasizes business values, such as functional rationality, cost-effectiveness and productivity and is in sharp opposition to the traditional democratic values of Swedish public administration, such as political democracy, public ethics and security of life and property (Lundquist, 1998). In the paper, a group of managers at CCV, referred to as the new management, is considered advocators of NPM. Especially they 2
favored the discourse of Total Quality Management (TQM), which is an important building block of NPM (Ferlie et al., 1996; Power, 1997). The ultimate aim of TQM is to re-define the organizational practice in a way that makes the customers' needs and demands become the point of reference for the development and the design of organizations (Deming, 1986; Hackman and Wageman, 1997; Juran, 1988). A group of senior administrators, the old administrators, resisted the deliberate attempt to institutionalize TQM, since they favored the traditional Swedish approach towards public administration.
The empirical case is presented in three passages, each followed by an analysis. The analysis displays that the dissimilar discourses and techniques advanced by the new management and the old administrators frame and discipline their worldview, which cause a lack of reflexivity amongst managers/administrators. In the discussion it is argued that the paper contributes to the study of institutionalization in two ways. First, it deepens the understanding of contradictions between conflicting social structures and, second, it elaborates on the relationship between the construction of subjectivity and institutionalization.
Theory: Institutionalization and disciplinary power
Ideals, discourse and techniques of control The neo-institutional empirical program has mainly focused on the isomorphism of highly taken for granted social structures, i.e. institutions, that give meaning to (organizational) life, such as the organization (Brunsson and Sahlin-Andersson, 2000; Meyer et al., 1994; Zucker, 1987), the rational actor (Brunsson, 1985/2000; Meyer and Rowan, 1977) and the market (Friedland and Alford, 1991; Granovetter, 1985) as well as how institutions/ideas are reproduced (DiMaggio, 1991; Galaskiewicz, 1991) and diffused through fields of organizations (Fligstein, 1991). These analysis have been done from the birds' eye point of view, which means that the discourses and techniques of control that the institutional rules consist of have not been focused - as argued in the introduction, the theoretical formulations have not been precise enough to direct empirical research. In order to deepen the study of institutionalization, the focus in the present paper is on the discursive and technical level of institutionalization. Following Hasselbladh and Kallinikos (2000) the concept of 3
institution is divided into three levels; the ideal level, the discursive and the technical level.
Institutions are conceived as consisting of basic ideals that are developed into distinctive ways of defining and acting upon reality (i.e. discourses), supported by elaborate system of measurement and documentation [i.e. techniques] for controlling action outcomes. (Hasselbladh and Kallinikos, 2000:704)
The distinction between ideals, discourse and techniques is derived from the "?degree of detail and precision by which they describe the social items and relations to which they refer" (Hasselbladh and Kallinikos, 2000:704). Ideals express themselves vaguely, discourses are more precise and techniques specify rather precisely how the social world should function or is functioning. As an example, the institution of organization, does, according to Brunsson and Sahlin-Andersson (2000), consist of three basic ideals (or values as they prefer to name them): hierarchy, identity and rationality. These ideals are, however, carried by several discourses, for instance TQM (but it can also be balance scorecard, business process reengineering or some other normative management program), which consists of several techniques, in the case of TQM, process orientation, measurement of customer perceived quality, etc (e.g. Furusten, 2000). Focusing on the discursive and the technical levels does, nevertheless, not imply that the ideals should be abandoned totally in the analysis, since local practice often are translated adaptations of ideals (Czarniawska and Joerges, 1996; Latour, 1987). But to put emphasis on the discursive and technical levels will sharpen the study of institutionalization - for example by specifying the contradictions between conflicting social structures - and direct the analysis to focus on knowledge and power, topics that are central in the works of Foucault (1977; 1981; 1986; Clegg, 1989).
Disciplinary power To Foucault power is not a state, nor do certain individuals have power, as is assumed in what Foucault entitles sovereign theories of power (Burrell, 1988; Clegg, 1989; Fulop et al., 1999), which have been the point of departure in neo-institutional empirical studies of power (Bealing Jr. et al., 1996; Collier, 2001; Dirsmith et al., 1997; McKay, 2001). Instead power is everywhere - it permeates the whole society.
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According to Foucault (1977; 1986), power controls the human body to a greater extent than the sovereign concept presupposes, why Foucault names it disciplinary power. Disciplinary power manifests itself through discourses and techniques of control, which make people behave and think in a distinctive manner - more distinct than the cultural rules, such as the organization and the rational actor, which neoinstitutionalists have focused on. A Foucauldian power analysis is thus not concerned with TQM as a deliberate management means to subordinate employees or the change of power relations as an effect of institutionalization of TQM. Rather the focus is on how TQM affects the thinking of collectives and individuals engaged with TQMwork. Disciplinary power poses the question: What effects does TQM have on the opinions, judgments and beliefs of people? TQM is for example likely to make managers value the opinion of the customer and the techniques developed to measure customer perceived quality most probably directs management attention to certain expressions of the organization that, according to the models, have a great impact on the quality evaluation made by the customer, such as the level of empathy, responsiveness and reliability/trustworthiness expressed by the front-line employees (e.g. Parasuraman et al., 1985).
The effect that TQM has on the thoughts of people can more fully be understood by the close relation Foucault presupposes between power and knowledge. According to Foucault (1981) the project of modernism has legitimated and formalized the production of (positivistic) truths. The truth like status of modern knowledge, and its legitimated character makes it affect the thinking of human beings. Knowledge is, however, never value-free. Instead it transmits certain values and is the most important carrier of power.
We should admit?that power produces knowledge?that power and knowledge directly imply one another; that there is no power relation without the correlative constitution of a field of knowledge, nor any knowledge that does not presuppose and constitute at the same time power relations. (Foucault 1977:27)
Rather than questioning the validity of modernistic truths or to focus on the intentional manipulative aspect of the production process of such truths, Foucault has concentrated on the effects "truths" have had on the constitution of human beings; in
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particular on the creation of subjectivity. Knights and Willmott (1989:554) have made explicit how Foucault defines subjectivity: "Rejecting the essentialist view of human nature, subjectivity is understood as a product of disciplinary mechanisms, techniques of surveillance and power/knowledge strategies". By the subjection caused by disciplinary discourse people are thus constituted as subjects (Foucault, 1977; 1981; 1986). TQM could accordingly cause a dramatic lack of reflexivity and openness since it introduces a way of seeing that directs attention to certain factors while excluding alternative ways of viewing the same reality. It could be suspected that TQM, as other "trendy" normative management discourses, has a definitive framing effect (Edenius and Hasselbladh, 2002); i.e. that it explicitly obstructs broadmindedness while it produces narrow-minded focus on the customers' needs.1 In addition, power/knowledge strategies of the past that have institutionalized the current practice of organizations, do, compared with TQM, constitute contradictory subjectivities and ways of seeing and acting upon reality. When TQM is introduced in a certain practice it can, furthermore, be expected that there will be disagreements between the advocators of TQM and those disciplined by the current practice. Such disagreements might, for example, cause de-coupling, that is TQM affecting the formal structure but not the actions of employees (Meyer and Rowan, 1977). By studying the conflicting ways of seeing reality the discourses and techniques of controls introduces it will be possible to explain the contradictions between social structures more fully, compared to a sole focus on the ideal level of institutionalization.
Summary When institutionalization is studied from a Foucauldian perspective the neoinstitutional birds eye point of view has to be abandoned. According to Foucault (1986) disciplinary power manifests itself through the discourses and techniques of every day life and not through ideals. When focusing on power from this perspective it is thus important to study how discourses and techniques affect the thinking of people in general and how people are created as subjects in particular - the "how" of power.
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Methodology The methodology approach of the paper can be called constructivist, which is found to be in line with Foucault's assumptions of social reality. With "constructivist" is here meant that TQM and other management discourses have a performative status; they serve "?to construct a particular field of visibility" (Miller and O'Leary, 1987:239). Rather than viewing TQM as a neutral tool for "seeing" reality it is acknowledged that TQM actively creates social reality. It can be argued that the performative character of a particular discourse and techniques of control associated with it are most visible in the actual process of organizing, why focusing on processes of institutionalization in a single organization is a advantage compared to a field focus.
The methods used to gather data of the TQM-work at CCV were interviews, participant observation and the study of documents. The empirical study lasted approximately two and a half years (from the fall of 1998 until the beginning of 2001). Altogether 60 hours of unstructured interviews were collected from CCV employees (mostly administrators, doctors, and nurses) as well as approximately two months' time of participant observation of meetings regarding CCV 2002 (extensive informal "chatting" not counted). In addition to this, everything written in the daily regional newspapers from 1990 to 2000 about CCV (approximately 25 folders of material) as well as internal documentation on organizational development that had taken place during the same time period was studied. The empirical material was structured with the help of Membership Categorization Analysis (MCA) technique (Silverman, 1993). Focus in this paper is on the administrators. The material was therefore initially ordered in several categories on the basis of the positions of the administrator and to what part of the organizations they belonged. The next step in the structuring process was to arrange these into main categories, a process called Membership Categorization Device (MCD). Silverman (1993) lists a number of rules on how MCD is to be constructed. The purpose with the rules is to help group the individuals so that those who are bonded through common views are placed in the same Membership Category. The MCD analysis resulted in the formation of two main categories - the new management and the old administrators - who struggled on what the official management discourse at CCV should be.
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Empirical case and analysis In this section the empirical case is presented in three passages. Each of them is followed by an analysis. Before the actual case is presented an account for the Swedish health care is made.
The Swedish health care, which principally is a public service, is divided into 28 geographic areas - County Councils (CCs) - that form detached administrative units. The governmental law of medical care provides a frame for each CC, but within this frame, freedom is quite extensive. Each CC has a political assembly and elections are held every four-year. The political body has the right to take up tax from the population of the county. Besides politicians, the CCs employ medical staff to do the actual health care and administrative staff to administer the decisions of the politicians. In Swedish doctrine of public administration it is an imperative that politicians should decide about what shall be done and the administrators ought to decide how these things should be done (Lundquist, 1988). During the 1990s' the Swedish health care suffered increasing budget deficit. This situation made the government implement a law in 1999 that stipulated that the finances of the CCs should be in balance by 2002 otherwise they could be subjected to administration by the state.
In response to this law several CCs implemented techniques for cutting costs. Most of them simply made budget cuts. The County Council of Värmland (CCV), however, implemented a TQM-program. The rational for this was that politicians and administrators thought that TQM should make people work more efficiently, which in turn could make CCV cut personal and then, off course, costs. The empirical case outlined in this paper concerns the TQM work at CCV between 1996 and 2001 as well as the prehistory of it from the beginning of the 1980s'. In the empirical presentation focus is on two groups of administrators; the new management (hired approximately at the same time as the TQM-program was introduced) and the old administrators (most of them had been working at CCV since the late 1970s).
Before the TQM-program The studied TQM-program (CCV 2002) was introduced at CCV in the middle of 1998 and was by most considered as an attempt to radically change the organization. The 8
reason for the latter was mainly that the formal organization at CCV had not been changed since the end of the 1970s. Back then a geographical based formal structure was introduced, dividing CCV into five administrative districts - the east, the west, the north, the south and the central district. Each of these districts had a hospital and was administratively run by a department director, medically by senior physicians. Each of the hospitals provided the population within their geographical area with basic care, which meant that they mostly served the older segment and children. The hospital in the central district was bigger and had more specialists and therefore provided more advanced health care to the whole population of Värmland as well as basic care to the population within the central district. There was also a central level at CCV with the office of the County Council Director (CCD) and among the staff there were the senior administrators. The CCD was not (formally) in charge over the five local departments, and most thought that this was an advantage, because decision concerning whole CCV was made in consensus in the managerial body of the CCD, where the department directors were members. The organization at CCV can thus be described as loosely coupled (Weick, 1979).
The management discourse at CCV was named the Värmland Way (VW) and was introduced by the same time as the new formal structure; in fact the structure was an effect of VWs central value; small-scaleness, even though it was put on paper later. With small-scaleness was meant that the five hospitals should remain. In internal documents three reasons for keeping the hospitals are presented. First, the five hospitals meet the need for closeness. The need for closeness was foremost a time issue in the emergency face, but also a social issue since relatives and friends easily could visit. Second, the kind of health care that was carried out at the hospitals was characterized by the need for different competences at the same time. The needed collaboration was thus enhanced in a smaller hospital, compared to a bigger one. Third, a smaller hospital was considered easier to manage than a bigger one (Internal documents).
Among the senior administrators at the central level the consensus concerning the management discourse was high - almost all of them thought that VW was the right way to organize the health care in Värmland. A major problem for them was, however, to handle the tension between the five administrative districts, which 9
became rife in times of budget negotiations. The final district budget was based on the annual budget estimates proposals made by the districts. In the beginning of the 1990s quite many thought that the budget process was unfair, since it favored those with good rhetoric skills rather than those with actual needs. The districts explicitly criticized the senior administrators at the central level, and implicitly VW, for not having developed a fair budget process. The debate in the regional media was at time intense and heated. As VW was dependent on the support from the districts a new budget technique, called population based budgeting, was developed in order to establish a more fair distribution of the economic means. This type of budgeting "?meant that we distributed money on the basis of the age structure of the population that the departments served" (senior administrator). The basis for that distribution was found in national statistics, which displayed that the cost of health care varied depending on age group. According to the administrators the new system made conflicts decrease, which most probably was the case since the debate in the media (concerning the issue of budgeting) decreased and after some time ceased.
Analysis The pre-history of the TQM work reveals VW as a distinctive and highly taken for granted, i.e. institutionalized, administrative discourse by senior administrators. VW seems to be a translation of the general Swedish ideal of public administration, which emphasizes democratic values, such as political democracy, public ethics and security of life and property (Lundquist, 1998). The central value of VW, small scaleness, manifests that. It hence seems that the administrative discourse at CCV is embedded in the institutional environment of the Swedish public sector. VW is a bit fuzzy at the technical level, but lately population based budget has been created to protect VW from criticism from the departments. Population based budgeting is a technique in line with the democratic values, manifested in VW, at CCV.
Interesting to note is that VW is unaffected by the new public management (NPM; Hood, 1995) ideal that begun to be popular within the Swedish field of health care at the end of the 1980s (Klausen and Ståhlberg ed., 1998). Rather, explicit arguments are formulated against that ideal in internal documents. The administrators seem to think that there is a fundamental opposition between NPM and the institutionalized approach to public administration. Another interesting aspect of the administrative 10
practice at CCV is that the administrators prefer to develop their own techniques instead of importing ready-made ones from the field. This is the case of population based budgeting. The administrators thus like to be independent in their creation of management techniques. This independence, however, is only a quasi independence, since they are disciplined by VW, which in turn is a translation of the ideal of public administration.
To conclude; VW is the taken for granted administrative discourse at CCV. The discourse is thus the legitimated systems of knowledge for administer health care. In accordance with Foucault (1977) VW disciplines and frames the actions and thoughts of the senior administrators. They are unwilling to embrace more recent ideas on how to manage public organizations.
The evaluation phase The first of December 1996 a new County Council Director (CCD) with great experience from administration in the field of social politics, but, however, not from managing health care, was hired. Almost everyone, politicians as well as administrators and physicians, thought that she was a successful recruitment. Within days after her arrival the politicians ordered her to do an inquiry. The inquiry was to center on how CCV could become a learning organization " ?where quality development from a customer perspective is the most central issue" (internal document). In addition to the inquiry an analysis of the environment was to be made. Two consultants got the latter mission and conducted a SWOT-analysis on the basis of interviews with prominent persons from public and private organizations within the region of Värmland. The two consultants reported no strengths, but quite many weaknesses. Amongst the later was that the administration suffered from lack of innovative power and CCV was characterized as a bureaucratic organization with a heavy "superstructure". Moreover, the systems of management were underdeveloped: "?CCV has an indistinct organization- and management structure, holistic approaches are lacking as well as overall strategies" (consultant report). The most important weakness in the health care was that the prevailing geographic organization caused ineffectiveness. "The care provided at each hospital has to be reviewed as well as the local management structure" (consultant report). The consultants thus implied that the formal structure would facilitate from being changed. According to the two 11
consultants the opportunity for CCV was to create a clear and consistent management culture, based on policies (which the consultants found missing in important areas) and a management philosophy.
A team that consisted of administrators, physicians and nurses, and was led by the new CCD handled the issue of learning organization and quality development. The general theme of the report that the team produced is that in order to form a learning organization and enhance quality development the processes should be developed guided by the customers needs and demands, the latter is a central thought in the TQM literature. Interestingly to note is also, that in the team conflicts arose between the CCD and two administrators, where the latter argued that they worked to fast and that no time for reflection was given which the administrators considered was not in line with thoughts of learning organization.
In 1997 the CCD also tried to strengthen the mandate of the central managerial body, which by most administrators was interpreted as a way for the CCD to increase her power and was therefore criticized. When the report of the consultants became public the conflict spread amongst the administrators of the organization, which was recognized by the CCD. "After two weeks the resistance was over me" (CCD). The conflict between the CCD and the administrators further increased when the former announced that the senior administrators' job-contracts were ended and that they would have to apply for their positions in competition with external candidates. The effect of this, besides that the conflict increased, was that three new senior administrators were hired amongst them the finance director who, together with the CCD, became the driving force of the TQM work within CCV.
Analysis Two interesting themes are to be noted from the empirical description in this subsection. One, that a new management discourse is imported to CCV, and two, that this new discourse is not very popular amongst the old administrators; the latter have been noticed in previous critical studies on TQM (Kelemen, 2000). It is a bit early to analyze the new management discourse in-depth, but it is certainly inspired by TQM and emphasizes values of formal control and effectiveness. This stands somewhat in opposition to the institutionalized administrative discourse, VW, which emphasized 12
democratic values and, as argued above, could be seen as an expression of the Swedish ideal of public administration (Lundquist, 1988). This ideal has lately, however, been challenged by the ideal of NPM (Hood, 1995), which emphasizes business values, such as functional rationality, cost-effectiveness and productivity (Lundquist, 1998; Power, 1997). The later ideal manifests itself through management discourses such as TQM (Furusten, 2000). One reason for the old administrators to resist the reforms announced by the CCD is thus that the new discourses stand in opposition to the institutionalized administrative discourse at CCV - in the frame of VW, TQM does not make sense to the old administrators.
The TQM program In spite of the conflict that arose between the CCD and the administrators at CCV the politicians decided to implement TQM. They probably thought that the conflict should ease since new senior administrators had been hired. The decision to implement TQM was taken in May 1998. Soon afterwards a task force was formed in order to start the process of implementation. This task force consisted of administrators, both new and old, senior physicians and some nurses. On the first and second meeting, a week in June and two days in August 1998, a business plan was written, that set out the basic thinking behind the TQM-work. Three goals were formulated: satisfied customers, satisfied employees, and balanced finances. The goal of satisfied customers and employees was to be measured each year. The measurements were to be linked to departments at CCV. If a department did not improve, some change at the department had to be carried out, for example a change in management.
It will take some time to establish the needed systems, but when we have them, when they are working; we will have a system that enables to put pressure on the middle managers [e.g. senior physicians and administrators] to fulfill their goals. If they don't do that we will simply replace them (finance director).
The actual TQM-work was to be carried out by process groups, which consisted of organizational members specializing in the area that the process group was responsible to develop, for example emergency care. The process groups should thus
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be responsible for adapting the overriding goal of the business plan into concrete goals for the specific discipline, and to implement this adapted version of TQM.
The next meeting of the task force centered on the work of the process groups. The basic idea was that the process groups should do their work during one internship week. When the members of the task force discussed the internship week, the senior physicians and the old administrators objected, because they could not let their personal be on leave for a whole week. The new finance director responded to that saying it is important for the process groups to be on a weeks meeting, arguing that their values and norms had to be changed if the TQM-program was going to be successfully implemented. The senior physicians, supported by the old administrators, said that they did not think that one week would change values and norms of their personal. The finance director and the CCD responded that the new way of working probably was unfamiliar to most of the members of the task force but they were quite sure that the TQM-work would change the values and norms of organizational members.
The conflict between the old administrators and the new management didn't ease until the CCD and the finance director, in late 1999, were forced to leave their positions, which also was the deathblow for CCV 2002. From interviews conducted with the new management and the old administrators during 2000 it is evident that they give different reasons to the emergence of the conflict. The new management thought that CCV was a very old fashioned organization that was unaffected by the NPM-reform program which they argued had affected most parts of the Swedish public sector.
After working 25 years in public organizations, CCV was a completely new experience. You haven't seen such a backward organization as CCV. (finance director).
In other words, the new management argued that CCVs history made the organization hard to change and that the old administrators didn't now how a modern organization should be managed. A second obstacle to change was, according to the new management, the administrative discourse VW.
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The overall policy driven by them [the old administrators] was that all five hospitals in Värmland should be preserved. This was stated in the Värmland Way, which was their baby, their creation. CCV 2002 had no such stipulated rule. Therefore they appeared as the knights and defenders of the five hospitals, which many thought was good to have. (CCD)
The new management criticized the prevalent practice for being inflexible and urged for a change, driven by the TQM program. The old administrators, which were proud of the organization that they had developed over the years, felt wrongly criticized, which according to them was one reason for the conflict.
Very much of the spirit here was; get rid of the past, weed out. This spirit became more evident when the finance director was hired; the spirit of rejecting history and put emphasis on the changes ?but things were not as bad as they [the new management] described it. If they had been a little keener to put emphasis on the positive side of our history, they could have been very sharp on the critique as well. The critique they put forward was to sweeping. If they had specified their critique, they might have established trust and mutual confidence. (Administrator)
The old administrators also thought of the new management as hypocrites, since the former argued that the latter's word and deed differed significantly. The new management said that organizational members should be given opportunity to involve himself or herself in the TQM-project, but according to the old administrators it was a widely-held opinion throughout the organization that only a few felt involved. The new managements ambition to formalize the loosely coupled organization was neither very popular amongst the old administrators.
We had an informal way of working here. We thought that this was an advantage. I once described it as we had a very informal structure with very well used paths. We walked those paths and had some shortcuts as well. But the new County Council Director never understood the advantage with those paths. In fact I don't think she ever saw them. She couldn't push herself throw all the virgin forest, maybe because she was more into the latest organization theory. I understood quite early that she did like to put all the theory that she had read into practice. (Administrator)
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To conclude, the new management thought that the old administrators were responsible for the creation of an old fashioned organization, which was hard to change. The discourse of VW obstructed change. The old administrators felt wrongly criticized, because they did not think that the prevailing practice was as bad as the new management said it to be. The old administrators thought that the new management couldn't see the bright sides of the practice of CCV because they were to occupied with all the "organization theory" they had read.
Analysis This section clearly reveals that there is an open resistance concerning TQM from the old administrators' point of view, and that they find support from the physicians. The major resistance is somewhat surprising since the old administrators as well as the physicians were involved in writing the overall business plan, which outlines the TQM ideas. It could, however, be argued that the details of the project and its implications become evident for the first time on the observed task force meeting. The physicians did not expect the introduction of the internship week, that the rational of this week was to change values and norms, that customer and employee attitudes should be measured etc. At first the old administrators and the physicians were seduced by the language of TQM - who can say no to the beautiful language of customer orientation, satisfied employees and finances in balance? But when TQM was translated into practice it became obvious that sacrifices would have to be done in other areas not initially spelled out by the TQM-advocators. When the techniques of TQM are introduced, when TQM should start to produce the effects it promises it becomes evident what sacrifices TQM demands. By acting in accordance with TQM, administrators and physicians push away the prevalent practice, which is the prime reason for the resistance of the TQM-initiatives.
But it also becomes evident that the old administrators were disciplined by the discourse of VW to the degree that they could not take in ideas that deviated from "the right way". They were unable to see the benefits of TQM and stuck to the old management discourse in spite of the acute financial situation it had created. The new management on their hand are prisoners of the TQM discourse. The management courses they have attended and the "organization theory" they have read and their experiences from other organizations all points to the fact that the practice of CCV 16
has to be changed radically. The ideas of customer orientation, productivity and efficiency are to them prerogatives and they are surprisingly much lacking the ability to value a more traditional approach to administer public organizations and the techniques connected to it. The "truths" that both groups believe in seem to determine their subjectivity to a great extent.
There thus seems to be a dramatic lack of reflexivity at CCV. The old administrators and the new management are almost completely disciplined by VW and TQM. The techniques associated with TQM and VW function as framing techniques; directing attention to certain areas of reality and introduces artificial management holism (Edenius and Hasselbladh, 2002). TQM seem to have the most distinctive framing effect due to the specifying character of TQM techniques. The interviews support this reasoning, since the new management TQM based argumentation is underlined by a performative rationale (Miller and O'Leary, 1987); the disciplinary effect of TQM makes them try to recreate reality. The new management completely lacked the eyes to see the problems that TQM caused at CCV.
Discussion and further research It is safe to say that a power analysis informed by the writings of Foucault focuses the construction of worldviews and subjectivity instead of the shift in power, which has been the focus in much previous empirical studies (Bealing Jr. et al., 1996; Collier, 2001; Dirsmith et al., 1997; McKay, 2001) of power within neo-institutionalism. In this section I will argue that the present paper has added to the study of institutionalization in two ways. First; it has elaborated on the increasing level of contradiction between conflicting social structures when they are translated from ideals to techniques via discourse. Second; it has implications for the relationship between construction of subjectivity and institutionalization.
Structural contradiction In the introduction of the paper it was argued that the neo-institutional theoretical formulations are not precise enough to direct empirical research. A distinction between ideal, discourses and techniques was made in order to connect neoinstitutional theory with the concept of disciplinary power, which was expected to
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precise the analysis. I believe that the Focualdian inspired analysis has served that point, which I tend to show by discussing the concept of de-coupling.
The effect of the studied TQM-program in terms of neo-institutional theory is quite clear. TQM ideas institutionalized the formal structure but became de-coupled to the taken for granted action and thought schemes of organizational members, since the core of the new management were forced to leave their positions. Following Meyer and Rowan (1977) the reason for de-coupling should be found in that there is a conflict between the technical core and the form undergoing institutionalization or between two or more social structures. In the case outlined in this paper we have seen a conflict between the new management and the old administrators, which restrained the process of institutionalization and led to de-coupling. According to Meyer and Rowans (1977) formulation of de-coupling this would be explained through the conflict between the traditional ideal of Swedish public administration, preferred bythe old administrators, and NPM, favored by the new management. On the ideal level, however, the contradiction between social structures is not total. Or to put it differently; the traditional Swedish ideal of public administration has room for some functional rationality and NPM has room for political democracy. Ideals do not control the action and thoughts of people precisely, which is assumed by the neoinstitutional field level research where the ideal level usually is the sole focus. The institution of organization (Brunsson and Sahlin-Andersson, 2000), referred to in the theory section, consists, as an example, of ideals (hierarchy, identity and rationality) that do not distinctly specify people's taken for granted action and thought schemes when institutionalized.
When the ideals are translated into discourses the level of contradiction increases. Organizational members disciplined by TQM discourse will hardly acknowledge the small-scaleness of VW; from the standpoint of TQM there is no such absolute values - the customer has to decide. The other way around, for advocators of VW, or similar translations of the Swedish ideal of public administration into local management discourse, it will be hard to accept the kind of customer-based evaluation of the organization that TQM introduces. When techniques are introduced in the analysis there is an even higher level of contradiction, which the techniques translated from NPM clearly demonstrate. Measurement of customer perceived quality directs senior 18
managers to replace middle managers that don't keep the scores high enough, which is in sharp opposition to the practice derived from VW. The techniques of TQM thus have an obvious preformative touch; people are defined and truly controlled by them. De-coupling is hence not solely explained by the conflict between ideals. The increasing and at the end almost total contradiction between discourse and techniques give explanations of de-coupling more precision.
There is, however, no per se contradiction on the discursive and technical level between two or more conflicting ideals, such as the doctrine of public administration and NPM. The ideal level leaves enough "translational space" for the adaptation of new discourses and techniques (or the standard versions of them applied) to the taken for granted discourses and techniques defining practice. It would be interesting to study institutionalization where discourses and techniques adapt to each other instead of the opposite. Such a study could contribute to the understanding of organizational and institutional change (Greenwood and Hinings, 1996) as well as to how colonization (Power, 1997) of organizations comes about.
Subjectivity In the introduction it was also stated that power in previous neo-institutional empirical analysis has been treated as an effect of institutionalization. In particular the students of institutionalization have shown how shifts in power take place when new forms are institutionalized in a field or in an organization (Bealing Jr. et al., 1996; Collier, 2001; Dirsmith et al., 1997; McKay, 2001). These studies have been based on the assumption that certain people or groups have power over others; an assumption that Foucault rejects (Foucault, 1977; 1986). From a Foucauldian perspective it will rather be claimed, as I intend to make explicit that this paper does, that power precedes and has a significant effect on institutionalization.
In the present paper it has been stressed that discursive practices of power/knowledge discipline people's thinking. In accordance with Foucault (1977, 1981) it could further be asserted that the disciplinarian effect of discourse has great impact on the constitution of subjects, especially in situations of organizational change. In the particular case analyzed here the Swedish ideal of public administration, the discourse of VW and the technique of population based budgeting produce the "bureaucratic" 19
subjectivity of the old administrators and that the ideal of NPM, the discourse of TQM and the techniques associated with TQM produce the "business" subjectivity of the new management. Subjectivity defines people's field of visibility. It can consequently be claimed that even if TQM does not institutionalize the practice of an organization it creates a field of visibility for the advocators of it. The same rationale probably follows from other power/knowledge practices that are popular today, such as Business Process Reengineering (BPR) and Balance Score Card (BSC). If the subjectivities produced differ, certainly the case at CCV, different interpretations of organizational change are made that affect the process of institutionalization. Taking a Foucauldian perspective, power shall, hence, not be treated as an effect of institutionalization. Rather, as an effect of disciplinary power manifest in discursive practices subjects are formed, which have great impact on institutionalization. If the focus in neo-institutional studies of power is on what power does to people rather than the change of power, power will be an explanation instead of a result, a cause instead of an effect.
The specific reform situation thus produces certain subjectivities with great impact on the process of institutionalization that neo-institutional theory has a problem to account for. In order to more fully understand what effect subjectivity has on institutionalization a cognitive micro theory is needed (Zucker, 1977/1991), such as the sensemaking perspective (Weick, 1979; 1995), which is "compatible" with a Foucauldian subjectivity concept. Such a design should be able to explain and make explicit how subjectivity is produced when organizations encounter change initiatives as well as how these subjectivities effect the very process of institutionalization. It would thus be interesting to study the micro processes of institutionalization with Weick's sensemaking theory in order to explain how subjects are constituted and the effect that such a process has on institutionalization.
Conclusion The present paper has offered a description of institutionalization as well as an analysis informed by Foucault's disciplinary power framework. The center of attention has been on how discourses and techniques discipline people's construction of reality and their thinking in general. It was argued that the approach taken had implications for the study of institutionalization, particularly on the contradiction 20
between conflicting social structures and the effect construction of subjectivity has on institutionalization. It was believed that the two mentioned areas were in need of further investigation in coming neo-institutional research. Studying
institutionalization from the perspective of disciplinary power thus offers interesting ways of conceptualizing and thinking of institutionalization.
Notes
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But according to Foucault (1977; see also Smart, 2002) TQM will most probably also have a productive effect; the focus on the customer might introduce a perspective that previously have been lacking in the organization, which might produce greater turnover or a more positive evaluation of the organization. Foucault (1973) have, for example, demonstrated how clinical observations established a new epistemological foundation in medicine, changing medicine from being a theoretical, scholastic occupation to establishing modern clinical medicine as the taken for granted discourse/knowledge. Clinical medicine have of course meant that diseases and illnesses is cured more efficiently than before, but it has also "framed" the thoughts and actions of physicians towards patients by introducing a certain subjectivity - effective alternative medicine are not used since they have not been tested following the techniques of clinical medicine.
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